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2. Customer Information
4. Customers Name:*
6. Service Address*
8. Home Phone
9. Work Phone
11. Cell Phone*
12. Email Address
14. Additional Cart Request
16. Please check the type of cart:*

    1. Trash
    2. Recycling

    If you would like to add both recycling and trash carts please check both.
17. Quantity of Trash Cart(s)*

    1. 1 Extra Cart - $6.83 per month
    2. 2 Extra Carts - $13.66 per month
    3. 3 Extra Carts - $20.49 per month
19. Quantity of Recycling Cart(s)*

    1. 1 Extra Cart - $6.83 per month
    2. 2 Extra Carts - $13.66 per month
    3. 3 Extra Carts - $20.49 per month
20. Total:
    Add all cost together associated with your request(s) and place total amount here.
22. Notes:
    Use this section to provide any notes to the utility department regarding this request.
24. Customers Acknowledgement
26. BY PROVIDING YOUR NAME BELOW, YOU ARE CERTIFYING THAT THE INFORMATION THAT YOU HAVE PROVIDED HEREIN IS TRUE AND CORRECT.*
    AGREED AND UNDERSTOOD:
28. Office Use Only
30. Date Request Sent to WM:
31. Ticket#:
32. Staff Initials:
Leave This Blank:


34. 1. Receive an email copy of this form.
35. Email address

    This field is not part of the form submission.

36. Submit

* indicates a required field